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ANNUAL REPORT OF ~? -- ~_l.E
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GUARDIAN OF THE PERSON ?'
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COURT O COMMON PLEAS OF _ - _ ~ -~
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( a..rn~a.~- ~~ COUNTY, PENNSYLVANIA ~' ~:~ __~
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ORPHANS' COURT DIVISION
Estate of ~~~' ( ~ ~~S ~ • I ~" `i^~1 M ~- , an Incapacitated Person
I. INTRODUCTION
/~, _ w
l ~~~ ~ . ~L ~ 6~ ~~~- ~'- ,was appointed
Plenary~L'mited Guardian of the Person by Decree of f ~-~0h'1 w 1-•~T~7~; .1.,
datcd ( o~ ~ -~~C~
A. This is the Annual Report for the period from
to (the "Report Period"); or
B. This is the Final Report for the period from ~%~L~~~
,.,
to ~ , ~~ Q ~ (the "Report Period"), and is filed
for the following reason:
I o The death of the Incapacitated Person. Date of death: ` ~ / ! ~ - l
2. The Guardianship was terminated by the Court by Decree of
J., dated
For a Fina[ Report, omit Sections II through Iii
Form G-03 rer_ 10.13-06
Page 1 of 4
Estate of ~ ,.S ~~ ~~~ ~ , an Incapacitated Person
II. PERSONAL DATA
AQe of the Inca acitated Person: ~~ Date of Birth: ~ 7~~
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III. LIVING ARRANGEMENTS
A. "Current address of the Incapacitated Person: f
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i
B. The Incapacitated Person's residence is:
own home /apartment
nursing home
Q boarding home /personal care home
Guardian's home /apartment
hospital or medical facility
relative's home (name, relationship and address)
other:
C. The Incapacitated Person has been in the present residence since ~ ~ CJ~ .~
. If the Incapacitated Person has moved within the
past year, state prior residence and reason(s) for move:
Form G-03 r-er 10.13.06 Page ~ Of ~
Estate of ~~ ~- ~ Z~ ~ ~ / - ' ~ ~L' ~~`"~ ~ , an Incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
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cam. , ~~ t
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IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person are as follows:
c,
B. Specify what, if any, social, medical, psychological and support services the
Incapacitated Person is receiving:
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S o c ~ ~ ~ ~C2-C~'`~`
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V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian of the Person that the guardianship should:
continue
be modified
~e terminated
Fo~,»~-03 ,~e,~ to~3_n6
Page 3 of 4
Estate of ~~ E? f ~L~~ ~~ ~ ~! `' c 4~ ~''~'d~~ , an Incapacitated Person
The reasons for the foregoing opinion are:
B. During the past year, the Guardian of the Person has visited the Incapacitated Person
--~
-> ~ ~ times with the average visit lasting ~ hours, `~ ~- minutes.
The report of a social service organization employed by the Guardian to oversee and
coordinate the care of the Incapacitated Person for the period covered by this Report mczy be
attached to supplement this Report.
I verify that the foregoing information is correct to the best of my knowledge,
information and belief; and that this Verification is subject to the penalties of 18 Pa. C.S.A. § 4904
relative to unsworn falsification to authorities. ~,_____---~
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fi b < ~_z--~ `.
Dale Signal of Guardian of the Personl
t~Lti ~'vl 6~ ~' , ~>
Name of-l ~of the Person (type or print)
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Address
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Ciry, State, Zip
x--71 ~ ~ ~ i _ ~ ~ <~, ~
Telephone
Fo,~mG-o3 ,~e,~. ro_t3_o6 Page 4 of 4